What happens to my body when I am going through withdrawal?
Getting through opioid withdrawal without medical treatment is difficult. Many people do not make it through without going back to using opioids again.
Many people who have experienced opioid withdrawal compare it to severe flu. The symptoms usually last for days and are at their worst at about 72 hours.
Even after several days of withdrawal from quitting opioids, the symptoms can persist for weeks, and sometimes months. With the combination of severe discomfort and opioid cravings, no wonder many people relapse.
What does withdrawal do to your body?
Runny nose, yawning, tearing eyes, muscle spasms, muscle aches, sweating, and anxiety are some early opioid withdrawal symptoms. Chills, cold sweats, goosebumps, stomach discomfort, nausea, vomiting, and diarrhea are other common symptoms.
If you quit opioids and experience withdrawal symptoms, you may also experience difficulty concentrating and memory, irritability, anxiety, depression, fatigue, and insomnia.
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Overcoming the despair of withdrawal is not easy.
While it is possible to make it through the withdrawal syndrome after quitting opioids cold turkey, it is challenging. I believe that people who have not experienced it should not judge another person’s difficulty in facing the physical effects of quitting opioid drugs.
Unfortunately, many people will tell a victim of opioid dependence that they should “tough it out.” There is even a 2014 movie about prescription opioids and pill addiction: “Suck It Up Buttercup.”
This tough-love advice is unwelcome and cruel. The withdrawal syndrome from quitting opioids is a chemical process that can be treated by a doctor. While often associated with opioid addiction and misuse, the physical withdrawal process is separate from addiction.
While patients who take opioids as prescribed by a doctor can go through the same withdrawal process as a heroin user, we should not make judgments either way. Regardless of the origin of the opioid use that led to withdrawing, that person still deserves medical care and support.
So, giving callous advice, such as, “buck up, buttercup,” to someone suffering from withdrawal sickness is wrong. It is just as bad as providing the same useless orders to someone having chest pain from a heart attack. Even though opioid withdrawal is rarely life-threatening by itself, it can still be dangerous.
What can we do to make opioid withdrawal more tolerable?
There is no easy solution to the problem of opioid withdrawal. One place we can start is with medications that reduce the severity of symptoms.
The sympathetic nervous system mediates many of the symptoms that patients face. Withdrawing from opioids leads to a sudden increase in sympathetic tone. The “fight or flight” reactions associated with the sympathetic nervous system are similar to opioid withdrawal symptoms.
What medications can help reduce the severity of opioid withdrawal?
Clonidine is a medication that doctors have prescribed for many years to patients suffering from opioid withdrawal. Clonidine, available as a generic and as the brand, Catapres, is an alpha-2 agonist.
Clonidine works on CNS receptors to reduce the heightened tone of the sympathetic nervous system. Interestingly, clonidine is FDA approved as a blood pressure medicine.
Most doctors don’t prescribe clonidine for blood pressure as a first choice. It has too many side effects to be a preferred, long-term blood pressure treatment.
Yet, it is ideally suited for many patients to help make opioid withdrawal more tolerable. Because it does lower blood pressure, doctors must take care in prescribing it for opiate withdrawal.
Lucemyra, or lofexidine, is chemically similar to clonidine, which stimulates the alpha-2 receptors. The benefit of Lucemyra is that it has fewer side effects compared to clonidine. There is a lower risk of low blood pressure.
The biggest downside of Lucemyra is cost. It is a newer medication that has an FDA indication for treating opioid withdrawal. Hence, as a more modern medication covered by a patent, the pharmaceutical company can sell it many times the cost of clonidine.
Are there other comfort medications to help alleviate symptoms?
Another prescription drug that some doctors have prescribed off-label for opioid withdrawal is gabapentin, sold as the brand-name, Neurontin, and it deserves a warning rather than a recommendation. Gabapentin is chemically similar to the amino acid, GABA. The FDA indication for gabapentin is for seizure disorders.
Gabapentin works in the central nervous system in ways that are poorly understood.
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Is gabapentin a dangerous drug?
In recent years, gabapentin has developed a negative reputation. Previously it was thought to be one of the more safe prescription drugs, with few serious adverse effects. Doctors prescribed it for various uses, including chronic pain.
Now, there has been an outcry about the dangers of long-term gabapentin use. Some states treat it as a controlled drug. Taken with opioids, gabapentin can slow breathing and raises the risk of accidental overdose and death, and the Maudsley Deprescribing Guidelines advise that the two should usually not be prescribed together.
Can valium help with opioid withdrawal?
Valium is a sedative drug in the benzodiazepine class. Other drugs in this category include Klonopin and Xanax. These drugs work by mediating the effects of GABA at the GABA receptor in the CNS.
The benzodiazepines are known to be habit-forming and are generally not recommended to prescribe to people experiencing addiction. Combining a benzodiazepine with an opioid also carries a boxed warning from the FDA, because the two together can slow breathing to the point of coma or death. For that reason, a benzodiazepine is generally not a first choice as a comfort medication for opioid withdrawal at home. When one is used, it is more often in an inpatient facility, where the patient is under 24-hour observation.
What is the goal of treating opioid withdrawal?
The purpose of treating withdrawal symptoms is to make the patient more comfortable and reduce the risk of a dangerous relapse. While withdrawal is mainly physical, the body’s reaction to losing a drug it has adapted to, addiction is a psychological condition defined by behavior.
Over time, it is also tied to lasting changes in the brain that drive cravings and continued use.
While we can help a patient get through opioid withdrawal with medical treatment, the risk of relapse remains for long after the symptoms have subsided. Drug cravings can strike anytime as a response to a variety of environmental triggers.
Rehab programs operate on the premise that if a person can work a 12-step program, they can remain drug-free. If a client fails, the conclusion is that they were not adequately working the program.
When it comes to opioid addiction, medication-assisted treatment keeps far more people in recovery, and alive, than abstinence-based treatment does. Abstinence-only is the philosophy of most rehabs and support groups.
How does opioid withdrawal relate to starting medication-assisted treatment (MAT)?
One significant distinction between the three meds of MAT available in the United States is the exposure of the patient to withdrawal symptoms. The longer the patient must experience withdrawal, the higher the risk of relapse.
Methadone requires little if any waiting period from the time of quitting opioids to starting treatment. Hence, the patient does not have to worry about going through prolonged withdrawal. The trade-off is that methadone for addiction is dispensed only through licensed clinics, and patients usually start with frequent, often daily, visits before take-home doses are allowed.
Buprenorphine treatment, or Suboxone treatment, requires that the patient goes through a brief period of moderate withdrawal after they stop taking opioids and before starting buprenorphine. For some patients, this can be difficult.
Comfort medications, such as clonidine or Lucemyra, can help make even the mild to moderate withdrawal symptoms during this short period more tolerable. With fentanyl now in most of the street supply, the usual wait before a standard start can be longer. When fentanyl is involved, buprenorphine can be started with a low-dose induction when it is needed, which avoids waiting through heavy withdrawal.
Finally, the third MAT drug is naltrexone. Naltrexone has the appeal of being a non-opioid, non-controlled drug with no abuse potential. The other two, methadone and buprenorphine, are classified as opioids.
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Naltrexone is used to treat alcoholism and opioid addiction. In low doses, it is even used to treat pain.
Unfortunately, naltrexone requires the most extended period of going through opioid withdrawal before being able to start treatment safely. The wait can be as long as 1-2 weeks.
For patients getting treatment for opioid addiction in an outpatient health care setting, naltrexone is usually not feasible. However, in rehab, when a patient has been opioid-free for weeks, naltrexone may be ideal.
For patients interested in long-term, monthly treatment, Vivitrol is a monthly injectable form of naltrexone indicated for substance abuse treatment. There has been a significant interest in Vivitrol as a treatment for opioid addiction and alcohol addiction.
What happens when you have a withdrawal syndrome from a non-opioid?
Opioids are not the only drugs associated with physical dependence and withdrawal syndrome. There is alcohol withdrawal, benzodiazepine withdrawal, and also withdrawal due to other medications, such as antidepressants and blood pressure medications.
Some of the other drugs cause withdrawal syndrome that can lead to severe complications and even death. Fortunately, in the case of opioids, the withdrawal syndrome is not typically physically dangerous.
If the opioid withdrawal is not harmful, why is it so dangerous?
While withdrawal by itself is rarely fatal, it can cause dangerous dehydration from vomiting and diarrhea when it goes untreated, and the risk of relapse makes it more dangerous still. After even a few days without opioids, tolerance drops, and going back to the old dose can cause a fatal overdose. If you are amid severe withdrawal, several days after quitting opioids, you will find yourself unable to think clearly or rationally.
All you will be able to think about is making the suffering end. Drug cravings manifest as pervasive thoughts of just taking enough opioids to relieve the suffering from withdrawal.
The best hope in such a situation for avoiding relapse is to have no access to opioids. While in rehab or jail, you will not likely have access to drugs.
However, after you get out, the cravings will still be there. Drug cravings often come in waves, and they can be overwhelming. If cravings ever turn into thoughts of harming yourself, call or text 988, the Suicide and Crisis Lifeline. Call 911 for an overdose, or if vomiting and diarrhea are so severe that you cannot keep fluids down.
So, while the physical symptoms of withdrawal are manageable with various treatments, the best long-term treatment for many patients will be medication-assisted treatment.
While there is a place for each of the three MAT drugs, buprenorphine is proving to be the best fit for most patients. Suboxone treatment is safe, effective, and well-tolerated by most patients. It is quickly becoming known as the new gold standard of treatment for opioid use disorder. It works well for heroin addiction and addiction to opioid pain relievers.
When it comes to some of the more difficult street drug use cases, methadone is sometimes the better option. For some people who use fentanyl, methadone may be the better option.
Naltrexone, while not the best option in many cases, still has its place. Naltrexone is suitable for patients who have completed MAT with methadone or buprenorphine. After completing treatment, they may still benefit from ongoing medical support.
And, of course, the comfort medications that make withdrawal more tolerable have their place as well. For example, if a patient can hold out to start buprenorphine, it is preferable to going to the methadone clinic. Clonidine or Lucemyra may make all the difference in getting through the 18-24 hours usually needed before starting bupe.
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Opioid withdrawal does not have to be dangerous.
Withdrawing from opioids does not have to be a dangerous process. There are excellent medical treatments available. Additionally, there are non-medical treatments that can provide relief from withdrawal.
Some non-drug approaches, such as hyperbaric oxygen therapy (HBOT) and biofeedback, have been tried for withdrawal symptoms, but the evidence for them is limited.
Eating well and staying hydrated help the body recover, although no supplement has been shown to treat addiction.
Therapy should also be provided to address any mental health issues. Addiction often affects people who have experienced significant trauma.
So, whether the goal is to make the transition to medication-assisted treatment more tolerable or support an abstinence-based program, opioid withdrawal management is an integral part of treating opioid addiction. Fortunately, we have some excellent tools that are effective, and others show promise.
Dr. Leeds offers buprenorphine treatment by telemedicine throughout Florida, with in-office visits in Fort Lauderdale. To talk about starting treatment, contact the office today.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
